Search the new health care reform bill for the word “specialist,” and you’ll only come up with a few citations. Search for “Primary Care,” and you’ll find many. “Wellness” brings up even more.

That is definitely telling us something about the Obama Administration’s priorities, says Mr. Gerry Sikorski, a Partner at Holland & Knight, a Washington, DC-based law firm (www.hklaw.com). Mr. Sikorski and his team of 85 health policy attorneys have “walked the Trail of Tears on health care reform” over the last few years, plumbing the depths of the Affordable Care Act, as the bill is known, in preparation for an inevitable onslaught of medicolegal, regulatory and policy disputes.

In an exclusive interview with Holistic Primary Care, Mr. Sikorski and members of his team threw back the curtain on the bill, offering physicians a glimpse of what they can expect in the coming years. Mr. Sikorski, a former congressman from Minnesota, will present a thorough look at the bill and it’s likely impact on primary care at Physicians Consulting Inc.’s upcoming 2010 Healthcare Conference, at the Red Rock in Las Vegas this October. (Learn more at www.2010Healthcareconference.com)

On the one hand, the bill is good news. It views primary care as the central lynch pin in care coordination, and it stresses the value of prevention. One of the administration’s main goals is to keep as many Americans as possible out of hospitals and tertiary care facilities. That will require the systems to do a far better job of prevention and out-patient chronic care than they have done to date.

The bad news is that the plan doesn’t put much money on the table for primary care doctors, beyond a fairly limited set of loan forgiveness programs, incentives for younger doctors, special bonuses for good performance on quality measures, rewards for adoption of electronic medical records, and strong support of the Patient Centered Medical Home model.

The Holland & Knight team doesn’t see the bill doing much to ease the pressures that have borne down on solo and small group primary care practices over the last decade. If anything, those pressures will intensify.

Big Goals, Bigger Questions

Ellen Riker, a policy expert on Mr. Sikorski’s team, said the legislation has three main stated goals: 1) cover the uninsured; 2) improve quality of care; and 3) “bend the cost curve,” ie, reduce overall national healthcare expenditure.

She believes the government will probably score high on the first objective, at least on paper. “They do a good job explaining how they will enable people to keep their existing employer-funded private insurance, and how they will expand Medicaid to include childless adults.” In aggregate, the plan will provide coverage of some sort for well over 30 million Americans currently uninsured.

On the matters of improving quality, strengthening health, and cutting costs, Ms. Riker is less sanguine. There is still very little consensus on what constitutes “quality” in health care, beyond a fairly narrow set of best practices and outcomes measures. This makes it hard to actually determine if the new systems will be delivering quality care.

On the cost-containment question, “No one is at all sure if the bill will accomplish this.”

Down & Out

The Obama administration is committed to reducing unnecessary hospitalizations, and eliminating use of emergency rooms as default primary care sites.

“The architects of this legislation are very focused on pushing care down and out,” said Mr. Sikorski, meaning that, “They want to get care out of hospitals and institutions and into the community, at disbursed sites.” The push for preventive medicine---which could create some real though limited incentives for holistically-minded clinicians—is aimed at averting preventable hospital admissions to the greatest extent possible.

The reform is all about non-institutional care and better coordination of outpatient chronic disease management. Health risk assessment, early disease detection, community-based disease management, and close patient monitoring across multiple sites are hallmarks of the reform. In part, this is why the administration is so ardent in pushing EMRs and healthcare IT.

The idea is to create a tightly networked flow of information and resources between hospitals, large multispecialty group practices and smaller, widely distributed community health centers. The hope is that better coordination of services and continuous interaction with patients will keep people from falling through the cracks, improving overall outcomes and reducing costs by preventing care redundancies and preventable acute episodes.

Align, Escape, or Perish

While the reform plan will create centrifugal momentum that drives care away from centralized hospital centers and outward into patients’ communities and homes, it will simultaneously exert tremendous centripetal force on solo doctors and small group practices, forcing them to aggregate and align with hospital systems and massive group practice networks.

“Even though the bill emphasizes primary care, it will still be difficult for solo practices to survive,” Ms. Riker predicted. “Yes, Medicaid will bring its payments up to Medicare levels in a couple of years, Medicare will include new bonus payments, and there will be incentives for health IT. But the reality is that electronic prescribing systems, EMRs and all these advanced IT systems are huge capital investments for solo and small practices. Integrated systems cost money, and ultimately, it’s about integrating with the hospital systems.”

Robert Bradner, another attorney at Holland & Knight, added that the drafters of reform are big believers in “safety in oversight.” The IT push is in part based on the belief that the more information you gather about what doctors are doing, the more predictable the clinical outcomes and the better the ability to contain costs. “Oversight generates reporting, which turns into more administrative oversight. It’s basically an electronic version of paperwork. The status quo wants to keep the status quo.”

Primary care workloads will continue to increase, but reimbursement will not. Mr. Sikorski said the final bill didn’t do as much as the original House bill would have to put some flooring under physician payments. Large group practices will make a go of it because they can obtain significant savings from volume discounts and shared overhead. Small practices will be at a clear disadvantage.

Mr. Sikorski said the architects of reform are, “very enamored of the employed physician model, which does have advantages in that it frees doctors from the administrative hassles and overhead of insurance-based fee for service private practice. “The people who wrote the bill think the Geisinger or Mayo models are the best way to deliver integrated care.”

Bottom line is that established practices will feel a lot more pressure to sell or at least create strong links with hospital-based systems or large networked group practices. “Younger primary care doctors are facing either becoming hospital employees or joining up with large group practices.”

An Unintended Consequence?

Of course, there are other options: concierge and direct pay models, house-call practices, and other innovative non-insurance, non-Medicare models. A small but clearly growing number of doctors are opting out of managed care plans and government programs in favor of these other models (see Despite Recession, Concierge Practices Show Brisk Growth, Excellent Outcomes)

Ms. Riker expects that trend to continue under reform, and this could have the unintended consequence of driving the very sort of inequitable, fragmented, multi-tiered system the administration is desperately trying to avoid.

“The last thing they want to see is a tiered system, with lots of different segments, and doctors opting out and serving only people who can afford to pay out of pocket. That was definitely not their intent. But the pressures on doctors will be huge, and it could very well go that way.”

Who You Callin’ “Midlevel”?

With upward of 32 million formerly uninsured Americans about to enter systems that are already woefully lacking in primary care doctors, won’t the reform plan push things to the brink?

The government recognizes there’s a huge shortfall in the primary care workforce, and has allocated $250 million—half of the $500 million earmarked in the ACA—for training of new primary care practitioners. That said, the plan for filling the gap centers more on increasing the number of non-MD “midlevel” practitioners than on bolstering the number of MDs in primary care. Those funds are aimed at training 500 new primary care MDs and 600 PAs by 2015

In the coming decade, we’re likely to see the number of advance practice nurses and physicians increase by well over 100,000, while the number of primary care MDs is expected to remain relatively flat.

The administration sees nurse practitioners and physician assistants as the civilian equivalent of medical corpsmen in the military, and they’ll be called on to play similar roles, taking over a greater portion of primary care responsibility from physicians. For many people newly insured under the reform plan, the primary link to the health care system at large will be a nurse or physician assistant, not an MD.

Cautious Hope for Holistic Care

The reform bill will require Medicare, Medicaid, and all health plans in the proposed exchanges to provide coverage for any and all services receiving a rating of “A” or “B” from the US Preventive Services Task Force, a division within the Agency for Healthcare Research & Quality (to view the list of recommended preventive services, visit: http://www.ahrq.gov/clinic/uspstf/uspsabrecs.htm

That could translate into increased coverage for services like nutrition counseling, obesity management, and lifestyle based management of common chronic diseases.

“It’s definitely part of a move toward a more holistic approach. Alternative and complementary medicine are definitely mentioned in the bill and will be looked at,” said Mr. Sikorski. To the extent that they support the “down and out” movement of care from major centers to community-based sites, wellness oriented services will gain favor.

However, the reality is that the covered benefits will still be fairly limited. The list of recommended services falls far short of what most practitioners of holistic, functional or naturopathic medicine would consider standard practice. “Coverage of preventive services will improve somewhat, but it’s definitely not going to go as far as covering food as medicine! Initially there was a lot of enthusiasm (about holistic services), but then fiscal reality set in. So in the end, it’s going to be primarily conventional medical services with a little extra for adjunctive preventive health care,” Mr. Sikorski said.

"You will probably have a better chance of making a living doing holistic medicine under the new system than you do under the current conditions. But it’s definitely not going to be easy. The plan is definitely not going to just hand you success.”

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